A Simple Way to Involve Frontline Clinicians in Managing Costs

Executive Summary

While there have been significant strides in providing frontline clinicians with quality information, they still lack the tools they need to play an active role in controlling the costs of care they provide. To date, only small steps have been taken at most health care systems (e.g., clarifying the costs of specific tests during the test-ordering process), and new clinical analytics systems that offer better insights into costs and efficiency often aren’t integrated into day-to-day clinical care. Worse, discussions at health care organizations about how to increase “overall value” too often degenerate into conversations about cost reduction, with participants forgetting that value means improving outcomes and costs. In 2016, the Scottish National Health Service (NHS Scotland) successfully piloted an approach to value improvement that took both cost and quality into account and turned the management of value into the basic task of the point-of-care manager. Value ceased to be a side initiative or something driven solely by top-level finance and executive leaders. The “lean accounting” method for measuring real, unallocated costs that was used came from the Institute for Healthcare Improvement and one of the authors (Brian Maskell). IHI had partnered with Maskell to combine a version of lean accounting that had been used in manufacturing with a point-of-care management system.

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While there have been significant strides in providing frontline clinicians with quality information, these clinicians still lack the tools they need to play an active role in controlling the costs of the care they provide. To date, only small steps have been taken at most health care systems (for example, clarifying the costs of specific tests during the test-ordering process), and new clinical analytics systems that offer better insights into costs and efficiency often aren’t integrated into day-to-day clinical care. Worse, discussions at health care organizations about how to increase “overall value” too often degenerate into conversations about cost reduction, with participants forgetting that delivering value means both improving outcomes and lowering costs.

In 2016 the Scottish National Health Service (NHS Scotland) piloted an approach to value improvement that took both cost and quality into account and turned the management of value into the basic task of the point-of-care manager. Value ceased to be a side initiative or something driven solely by top-level finance and executive leaders.

The “lean accounting” method for measuring real, unallocated costs used came from the Institute for Healthcare Improvement and one of us (Brian). IHI had partnered with him to combine a version of lean accounting that had been used in manufacturing with a point-of-care management system.

The overall approach included three foundational elements:

a simplified method to understand quality, cost, and workforce capacity on a weekly basis

a visual management system to present and analyze this data regularly, engaging the entire team and linking measures to active, ongoing efforts to make improvements to cost and quality

a daily, point-of-care communication method to support continuous improvement through practices such as huddles and staff coaching

The approach was pilot tested in two successive stages over a one-year period at Raigmore Hospital, the largest hospital in the Highlands region of Scotland. The methods were tested in a single respiratory medical unit in Stage 1, then implemented in four cardiac units in Stage 2, and are now being rolled out throughout the hospital in Stage 3. In each successive stage, results began to emerge within two to six months of initiation of testing. Early-stage planning is under way to introduce the methods in other regions in Scotland, beginning in 2018.

The following tools constitute the basic building blocks of the value-management system.

The box score. Point-of-care teams use a “box score” (see the example below) that brings together a parsimonious set of three categories of measures onto a single page:

Five or six performance measures (quality metrics such as length of stay or readmission rates) show unit-level performance against organization-level strategic goals.

Measures of staff capacity explicitly track direct care (time spent with the patient), indirect care (time spent on non-patient-facing tasks), and available staff time (the remainder).

Financial measures report variable costs broken out by a few major categories (including supplies, drugs, and staff) along with revenue and margin measures.

The clinical team works together with finance and quality-measurement staff to update this box score every week.

The visual management board. This links the box score to a small set of targeted improvement projects (see the example below). The board presents graphical displays (run charts) of key metrics derived from the box score, enabling frontline teams to monitor performance over time, identify key gaps in performance, and describe local project-based initiatives to improve cost or quality of the local system. Teams usually select five or six measures from their box score for further analysis. The team presents a run chart for the measure below the box score, a Pareto analysis showing key drivers of variation, and charters for projects to improve performance.

A routine, in-person reporting and communication approach. A management-communication approach is then used to integrate these tools into daily work and engage the local team in continuously tracking performance and implementing improvements to reduce costs, increase quality, and better utilize staff capacity.

Insight Center

This includes conducting brief daily team huddles and more thorough weekly huddles around the visual management board to update the box score, review measures (including the factors contributing to performance), discuss improvement projects, and address any barriers to progress. Together these tools and management approaches empower frontline teams to utilize insights from the continuous flow of data, logically prioritize the implementation of targeted initiatives, and deliver more sustainable improvements.

Implementation of the approach included coaching on the fundamentals of improvement work (plan-do-study-act methods), help in assembling the initial box score, coaching during initial weekly team huddles in front of the visual board, and advising on individual improvement projects flowing from the performance analysis. After an initial period, local coaching and facilitation capabilities were developed at Raigmore Hospital to facilitate the spread and scale-up of the approach system-wide.

Thus far, results are promising. The respiratory unit — the earliest pilot unit, which started work several months in advance of the others — has seen a reduction in patient falls (achieving the greatest number of patient days between falls ever on the ward during the project); improved staff satisfaction (with nearly all staff consistently self-reporting themselves as satisfied at work each day); and a 15.1% decline in cost per patient seen (see the exhibit below). Cost reductions were due to increases in productivity, along with reductions in drug waste and per diem nursing costs.

Other teams have also seen progress. The cardiac intensive unit has seen fewer inappropriate admissions — ensuring that high-intensity beds and resources are available for patients that truly need them. Another unit has eliminated hundreds of pounds in drug waste and changed its overall approach to stocking materials such as angioplasty balloons (for example, making cheaper versions more readily accessible to staff than more expensive versions). The cardiac catheterization lab has begun to reduce downtime periods when the lab was staffed but wasn’t operating (due to lack of physician availability or patients) by addressing demand for elective procedural services in the community. Finally, one medical unit has identified and begun to address high rates of falls, which resulted in increased length of stay and corresponding costs.

This testing in NHS Scotland has taught us several lessons about the approach to managing value in a busy health care environment. First, point-of-care leaders, if armed with information about costs and quality, can improve both.

Second, strong point-of-care leaders determine success or failure. Each team should have two leaders who take ownership of this work. At least one senior nurse, or a similar role, will need to ensure timely data updates and spearhead improvement efforts while working to engage other staff. Another leader should support the first leader, facilitating huddles when the other leader is absent.

Third, many health systems expect that a value-management system with cost information in close to real time will require a sophisticated data analytics capacity. We have not found this to be necessary. Sophisticated analytics usually overwhelms the capacity of the front line to make improvements. What is needed is actionable data: just enough information about cost, supplied in close to real time so that staff can act on the data and make improvements. Data that is two to three months old challenges human memory and makes useful change very difficult. Collaboration with data and financial staff can make weekly updates feasible without significant additional work. Automating the data collection and reporting is needed, however, to roll out the approach across the full hospital and ultimately across the entire health system.

Fourth, many clinical teams expect a focus on costs to alienate or demoralize staff and turn off physicians. We have not found this to be the case. In fact, staff in the initial units reported greater job satisfaction as they gained more control over their financial performance and were less subject to what they perceived as arbitrary austerity measures. Physician buy-in and support were obtained through a focus on improving clinical performance on the service units. That resulted in fewer falls, better adherence to guideline-based care, and fewer instances of patients being admitted to the wrong service units (for example, routine patients to intensive care, or surgical patients to a medical ward).

Fifth, executive buy-in means there should be an executive-level visual management board, box score, and huddles. This executive dashboard should draw from the unit-level visual management boards, creating a consistent and coherent system of performance management.

Above all, these methods offer point-of-care teams a powerful set of tools to identify trends, manage costs, increase efficiency, and better utilize staff capacity. The engaged teams at Raigmore Hospital have felt a new sense of empowerment since the introduction of this approach. Some participants say that without the value-improvement approach, they would never have had a clear understanding of how money is spent or an opportunity to do anything about it.

Leaders in the health system to which the acute hospital belongs agreed that one of the most significant benefits of the method included improved multidisciplinary communication and problem solving. “We have moved on from sterile debates about budget overspends based on out-of-date information to dynamic discussions about reducing next week’s costs based on this week’s information,” says Nick Kenton, the board-wide director of finance during the initial project roll-out.

Too often, value-improvement efforts start at a conceptual level in the organization or with sweeping austerity measures. While these steps may be effective at times, they come with consequences and may not be the swiftest or most sustainable solutions to financial pressures that are widely felt across the world’s health systems. The value-management methods described here have created sustainable systems that more broadly engage clinical staff, and they should serve as a foundational step as health care organizations in the United Kingdom, the United States, and elsewhere work to deliver better care at a lower cost.

Kedar S. Mate, MD, is the chief innovation and education officer at the Institute for Healthcare Improvement and an assistant professor of medicine at Weill Cornell Medical College.

Jeffrey Rakover is a senior research associate on the Innovation Team at the Institute for Healthcare Improvement.

Kay Cordiner is the senior charge nurse of a respiratory Unit in Raigmore Hospital in the Highland region of the National Health Service Scotland.

Brian Maskell is president of BMA, a consulting firm that specializes in lean accounting and lean management.